Dissociative Disorders, Somatic Symptom Disorders, Elimination Disorders, and Sleep-Wake Disorders

Dissociation

Unbidden loss of continuity in subjective experience, pathological “checking out”

Depersonalization

Feeling of detachment from self or looking at self as an outsider would

Derealization

Detachment from environment, sense environment is unreal or foreign (previously familiar); dream like

Amnesia

Inability to account by memory for a significant block of time that has passed

Dissociative Identity Disorder

• Patient has at least two clearly individual personalities, each with unique attributes & control of thought and behavior

• Memory gaps for personal information and recent experiences

• Often self-perception following trauma

• Not a normal part of broadly accepted cultural or religious practice

Children experiencing DID:

• Excludes normal imaginary friends and play

• Identities may vary

• May or may not be aware of their gender and identities may have their own names

• Identities may be aware of one another

• Transition may occur suddenly & may be percipitiated by stress

• Considerations for informed consent & therapy

Dissociative Amnesia

Main Requirements

1) Patient has forgotten an important autobiographical event, usually traumatic

2) Inconsistent with normal forgetfulness

3) Other disorders have been ruled out

Dissociative Amnesia with Dissociative Fugue

Patient suddenly journeys away from home

• May experience disorientation and perplexity

• Usually a brief episode of travel, lasting a few hours or days

• Recovery may be sudden

Depersonalization/Derealization Disorder

• Patient repeatedly experiences (persistent and recurrent) depersonalization or derealization

• Roughly half of adults have at least one episode, so dx should be limited

Dissociative Disorders Treatment

• Psychotherapy (Cognitive, psychotherapy, EMDR)

• Grounding Techniques/Skills (hold an ice cube, cold water, stomping)

• Mindfulness

• Psychopharmacology (SSRIs, Anti-anxiety such as Clornazepam)

Problems that can suggest somatic symptom disorder

• Excessive or chronic pain

• Functional neurological symptoms (nervous system)

Somatic Symptom Disorder

• At least 1 distressing or disruptive somatic symptom

• Excessive thoughts, feelings, behaviors related to somatic symptoms manifested by at least 1 of the following:

  • Disproportionate & persistent thoughts about the seriousness of one’s symptoms

  • Persistently high levels of anxiety about symptoms/health

  • Excessive time/energy devoted to symptoms/health concerns

    • Symptomatic for at least 6 months

Illness Anxiety Disorder

• Persistent worry/anxiety about having a serious illness

• Somatic symptoms minimally present or absent

• Easily alarmed about health status

• Excessive health-related behaviors

• Patient may reject any suggestion that they don’t have that disease

Factitious Disorder (Munchausen Syndrome)

• Intentionally producing symptoms to assume a sick role and gain medical attention

• Complaining of symptoms such as depression, hallucinations, anxiety, disorganized behavior

• Can be difficult to detect

Factitious Disorder: Imposed on Self

Patient is misleading about their symptoms

Factitious Disorder: Imposed on Another (by proxy)

• Caregiver causes factitious symptoms in another person and bears the diagnosis

• Individual presents another individual (victim) to others as ill, impaired, or injured

• Deceptive behavior is evident in the absence of external rewards

Enuresis

Repeated voiding of urine into bed or clothes, involuntary or intentional

• 2x a week for 3 months

• Nocturnal only

• Diurnal Only

• Nocturnal or Diurnal

Encioresis

• Repeated passage of feces into inappropriate places (clothing, floor)

• One event each month for 3 months

• Chronological age at least 4

Insomnia

Too little sleep

Hypersomolence

Excessive sleepiness

Insomnia Disorder

• Complaint that sleep is too brief or unrestful

• Difficulty initiating or maintaining sleep

• Early morning awakening without returning to sleep

• At least 3 months

• Activities in bed other than sleep or sex; poor sleep hygiene

Hypersomnolence Disorder

• Excessive sleeping despite a main sleep period lasting at least 7 hours

• Tend to fall asleep within 5 minutes

• Trouble remaining fully awake/alert (sleep inertia)

• Occurs 3x a week for 3 months

Narcolepsy

Recurrent periods of irresistible need to sleep, lapsing into sleep, or napping

Narcolepsy symptoms

• Sleep attacks: REM sleep intruding upon normal waking state

• Cataplexy: sudden, brief episodes of paralysis that can affect all voluntary muscles, may result if complete collapse if all muscles affected

• Hallucinations: mainly visual, hinting that REM sleep is suddenly intruding upon waking state

• Sleep Paralysis: sensation of being awake, but unable to move, speak, or breathe adequately, may be accompanied by visual or auditory hallucinations

Sleep-Wake Disorders Treatment

• Referral for sleep study

• Psychoeducation and goals centered around sleep hygiene

• Treating issues that may be related to sleep problems (substance use, trauma, anxiety, depression)